Prevalence of low back pain and associated factors among bank workers at Hawassa city, Northern Zone, Sidama Region, Southern Ethiopia

Background Lower back pain (LBP) is a public health threat that affects people who frequently experience sedentary working conditions. Few studies reported on low back pain among bank workers in Ethiopia, particularly in the study area. Therefore, this study aimed to determine the magnitude and associated factors of low back pain among bank workers in Hawassa City, Sidama Region, Ethiopia. Methods This institutional-based cross-sectional study was conducted from April 20, 2023, to June 30, 2023. A multistage sampling technique was employed to select participants, and data were collected using a structured self-administered questionnaire, entered into Epidata version 4.6, and transferred to SPSS version 25 for further analysis. Bivariate and multivariate logistic regression analyses were performed to identify the independent predictors of lower back pain. Results Of the 627 total study participants, six hundred seven bank workers participated in the study, with a response rate of 96.8%. The overall magnitude of lower back pain among the study population was 55.2%, with a 95% confidence interval (CI 51.1–59). Based on the multivariate binary logistic regression analysis, being in a manager position (AOR = 3.85; 95% CI = (1.2,12), a level 2 banker (AOR = 3.8; 95% CI = (1.9,8.9), age 30–39 years (AOR = 4; 95% CI = (2,12.4), an age ≥ 40 years (AOR = 5.4; 95% CI= (3.04,16.3), working in sufficient space (AOR = 0.4; 95% CI = (0.3,0.9), and physical activity (AOR = 0.2; 95% CI = (0.1,0.8)) were significantly associated with low back pain. Conclusion The prevalence of low back pain among the bank workers was high in the study area. Being in a managerial position, being a level two banker, being aged 30–39 years, being aged ≥ 40 years, working in sufficient space, and engaging in physical activity were significantly associated. Therefore, it is essential to establish a health screening team, create awareness programs for the benefit of physical activity, provide sufficient working space, and give special attention to elderly and senior bankers and bank managers to reduce the risk of developing low back pain.


Background
Low back pain (LBP) is defined as short or persistent pain of the lower spinal cord, especially in the lumbar and sacral regions, and sometimes radiates toward the buttocks and lower legs.It is related to work-linked and uncomfortable postures [1].LBP is a global public health concern that affects people who are frequently enrolled in sedentary working conditions and is a very common problem of the musculoskeletal system associated with working conditions [2,3].
Occupation-associated factors are inseparable from low back pain.Any sedentary work that takes a long time, high workload, or irregular sitting preparation are the existing reasons for LBP [4].The working style of bank workers is most commonly stagnant, and the alignment of their boards, computers, and tables is not adjusted or designed according to their health condition [5].LBP among office workers, including bankers, leads to a negative economic impact, which including an increased absence from work and lost productivity, and has global implications for various sectors, such as economic, societal, and public health [6,7].
LBP is a significant global public health concern affecting millions of people across different region.According to a 2016 assessment of the global burden of diseases, injuries, and risk factors, low back pain (LBP) was among the top 328 morbidities for any population category [8].Globally, several studies have shown that office workers have a 1-month incidence of LBP, ranging from 23 to 46% [9,10].According to a World Health Organization report, in 2020, LBP had a considerable impact on 619 million people, with projections indicating a further increase to 843 million cases by 2050.It has been suggested that low-income countries have a higher frequency of LBP than high-income countries [9].In Africa, a systematic review of population-based studies among children, adolescents, and adults estimated the lifetime (47%), annual (57%), and point (39%) prevalence of LB [11].A study conducted in Dhaka, Bangladesh and Kigali, Rwanda, revealed that the prevalence of low back pain among bank workers was 36.6% and 45.8%, respectively [12,13].In Ethiopia, the point and twelve-month prevalence of LBP among the working population are 49% and 56%, respectively [14], and studies conducted in Addis Abeba, Jimma, and Gonder, Ethiopia, have shown that the prevalence of low back pain was 54.3%, 54%, and 55.4%, respectively [15][16][17].
Age, smoking, weight lifting, stooping, prolonged sitting, poor fitness, sedentary lifestyle, awkward posture at work, work experience, obesity, occupational stress, working conditions, long office hours, working in the same posture, and continuing the same job for many years were identified as the factors most strongly associated with LBP [12,[17][18][19].
The health problems associated with quality of life, disability, and economic influence as a result of health care expenses require ongoing public health interventions [3,20,21].Determining the prevalence of low back pain provides a foundation for targeted interventions, research advancements, and improved well-being of bank workers.It also helps researchers prioritize studies related to low back pain, the development of evidence-based practices, and therapists in designing exercise programs, ergonomic adjustments, and stress management techniques to effectively address low back pain effectively and educate bank workers on preventive measures, emphasizing the importance of physical activity, stress reduction, and maintaining a healthy lifestyle.However, in Ethiopia, particularly in the study area, there are limited studies on the magnitude of LBP that can help establish planning strategies for the prevention and control of LBP among bankers.Therefore, this study aimed to determine the magnitude of low back pain and its associated factors among bank workers in Hawassa City, Sidama Region, Ethiopia.

Study design
This cross-sectional study conducted from April 20, 2023, to June 30, 2023, among bank workers in Hawassa City, which is located in the Great Rift Valley, 275 km south of Addis Ababa.The city serves as the capital of Sidama National Regional State.According to 2016 Ethiopian Central Statistics Agency (CSA) data, the city had a population of 351,469.The city is home to many institutions that serve businesses and provide public services.There is one public bank with 31 branches a nd 42 private banks comprising 2669 bank workers.

Population, sample size determination, and sampling techniques
All bank workers and bank workers who are in the selected banks in Hawassa City were the source and study population, respectively.
The survey included all Hawassa City bank employees who had been employed for a minimum of six months.A female employee or pregnant woman working at a bank with a child under six months of age, a previous surgical history of pelvic surgery, spinal surgery, LUCS, and other procedures; any history of back pain or other spinal injuries resulting from accidents (such as car accidents); a history of protrusion of the lumbar intervertebral disc, joint or bone disorders, or any history of persistent inflammatory pain (such as rheumatoid arthritis, ankylosing spondylitis, etc.); and bank workers with previous trauma were excluded from the study.
The sample size was determined using a single population proportion formula by considering the proportion of LBP among bank workers in Gondar City [17], which was approximately 55.4%, with a 95% confidence interval and a 5% margin of error.The final sample size was 627, after using a design effect of 1.5 and a 10% nonresponse rate.

Sampling technique and procedure
A multi-stage sampling technique was used in this study.In the northern zone of the Sidaama region, Ethiopia, there were three city administrations; of the three city administrations, Hawassa City was randomly selected.There are eight sub-cities in Hawassa City; four of them-Menariya, Tabor, and Mehali sub-cities-were selected at random by the lottery technique.The number of banks in each sub-city was then proportionally calculated.Study participants were assigned to each bank using probability proportional to size (PPS) and were chosen using a simple random sampling method.

Data collection instruments and procedures
Data were collected using structured, pretested, selfadministered questionnaires adopted from the Nordic Musculoskeletal System Disorder [22] and adapted from similar studies performed previously on low back pain among bank workers.The questionnaires prepared in English language -were translated into the local language (Amharic) and retranslated back into English to check the consistency of their meaning.The data were collected via the Amharic version of the questionnaire by one BSc in Environmental Health and one BSc nurse and supervised by one MPH in Public Health who has experienced similar studies.One-day training was given to the data collectors and supervisors about the aim of the research, the data collection technique, ethical issues, and the content of the research in an understandable way.Every day, each completed questionnaire was checked for completeness, and the principal investigator controlled the overall data collection process.

Data quality assurance
The questionnaire was prepared in English, then translated into Amharic, and finally retranslated back into English by independent translators to check for consistency.A pre-test was conducted on 5% of the sample size at the Alamura and Gebriel branches of the Commercial Bank of Ethiopia (CBE), which were not selected for the study.The supervisor reviewed the questionnaires daily to ensure uniformity, completeness, consistency, and missing data.The principal investigator held a brief meeting with the supervisor each day to verify the correct data collection before data collection was completed.

Operational definition
Low back pain A ba nk worker who had a perceived ache, pain, or discomfort localized below the coastal mar-gin and above the inferior gluteal fold during the last 12 months was considered to have LBP [17].
Bank workers employees who perform financial activities that include supervision, customer service, public relations, accounting clerks, loan officers, and managers [16].
Exercise performing physical activity or performing any kind of sports activity, including walking, for at least 150 min per week [23].
Smoking cigarettes Workers who had daily experience smoking approximately 1-4 cigarettes per day were considered light smokers, and those who smoked > 4 cigarettes were considered heavy smokers [24].
Alcohol consumption Bank workers who are legal of drinking age and who drink two or more drinks that contain alcohol per day are considered to consume alcohol [25].

Statistical analysis
Data were entered, cleaned, coded into EpiData version 4.6, and transferred to SPSS version 25 for further analysis.Descriptive statistics such as frequencies, percentages, and interquartile ranges were computed.Bivariate and multivariate logistic regression models were used to determine the degree of association between outcome and predictor variables.Independent variables with a P value less than 0.25 in the bivariable analysis were selected for multivariable logistic regression analysis.Multivariable logistic regression analysis was performed to identify statistically significant variables.Statistical significance was set at a P-value of less than 0.05.The model's fitness was checked using Hosmer and Lemeshow's goodness-of-fit test, and the results were considered significant at a p-value greater than 0.05.The variance inflation factor (VIF) was used to evaluate the potential for multicollinearity among independent variables.

Sociodemographic characteristics of the participants
A total of 627 bank workers participated in the study, with a 96.78% response rate.Of the 607 respondents, 315 (51.9%) were male.The mean age of the participants was 32.85 ± 6.8 years.Of the total participants, 507 (83.5%) were under the age of 40 and 491 (80.9%) were in the Level 1 banker position (Table 1).

Work-related characteristics
More than two-thirds of the study participants 427(70.3%)had 8-12 working hours, and slightly more than half of the study participants 348(57.3%)had no training in workplace safety.Most participants 548(90.3%)used computers for their daily activities, and approximately two-thirds 382(62.9%)used computers for ≥ 6 h.Majority of the study participants 418(69.9%)had no ergonomic training.Half of the participants 324(53.3%)reported that they had insufficient space to properly perform their work (Table 2).

The magnitude of lower back pain
According to this study, the prevalence of the bank employees' 12-month LBP was 55.2%, with a 95% confidence interval (CI 51.1-59).Because of their LBP, nearly three-fourths (69.9%) of the respondents did not quit their jobs, 38.8% claimed that standing for extended periods worsened their pain, and 67.1% of study participants found that resting helped them feel better (Table 4).

Factors associated with LBP
According to the binary logistic regression, monthly income, education level, job position, work hours per day, training on workplace safety, sufficient work space, training on ergometric issues, and body mass index (BMI) were factors associated with LBP.However, being in a managerial position, being a level 2 banker, being aged 30-39 years and ≥ 40 years, work space sufficiency, and physical activity were significantly associated factors in the multivariable logistic regression analysis.The odds of LBP were 3.9 times greater for bank workers who were in a managerial position than for bank workers who were not (AOR = 3.85; 95% CI = 1.2, 12).Bankers aged 30-39 and ≥ 40 years had 4-and 5-fold greater odds of having LBP, respectively, than bankers aged 20-29 years (AOR = 4; 95% CI = 2,12.4and AOR = 5.4; 95% CI = 3.04,16.3,respectively).The odds of LBP were 80% lower for bank workers who performed regular physical activities than for their counterparts (AOR = 0.2, 95% CI = 0.1-0.8).Bankers who worked in a sufficient space were 60% less likely to develop LBP than those who worked in an insufficient space (AOR = 0.4; 95% CI = 0.3-0.9).The odds of LBP were 3.8 times greater for bank workers who were at level two than for those who were at level one (AOR = 3.8; 95% CI = (1.9,8.9)) (Table 5).

Discussion
This study assessed the prevalence of low back pain and its associated factors among bank workers in Hawassa City, Sidama Region, Ethiopia.
This study found that a substantial proportion of bank employees (55.2%) were affected by LBP.This finding was supported by the 95% confidence interval, which ranged from 51.1% to 59%.This indicates that back pain is common among bank employees in the study area.The high prevalence of low back pain among bank workers in this study could result in problems with day-to-day activities and performance at work, a significant economic burden, and the cause of personal hardship.It also reduces the productivity of employees by challenging them to perform their tasks efficiently, resulting in frequent absences that can disrupt workflow and impact overall team performance; workforce absenteeism affects staffing levels, customer service, and operational continuity, affecting the quality of customer service by making it more difficult for bank employees to maintain a positive demeanor, answering queries, and providing efficient service and costs for healthcare, resulting in stress, anxiety, frustration, and affecting their overall well-being.
. According to our study, bank employees aged between 30 and 39 years and those aged ≥ 40 years were more likely   to experience back pain than employees aged between 20 and 29 years.This finding aligns with a previous study in Dhaka, Bangladesh [12], which revealed that people older than 40 years had a greater risk of lower back pain than those in younger age groups.Another study in the United States highlighted the association between advanced age and low back pain.This may be because older age is a major risk factor for LBP [26].Another reason could be that, as workers age, they may experience increased susceptibility to LBP due to factors such as reduced muscle strength, flexibility, and degenerative changes in the spine.
Additionally, this study demonstrated that physically active bankers had a lower likelihood of experiencing lower back pain than those who did not.This result is consistent with a study conducted in Dhaka, Bangladesh [12], which may be because the spine can become misaligned due to weak or shortened muscles; on the other hand, regular exercise can strengthen the muscles that support and maitain the spine in ideal alignment for optimal performance [27].Another cause could be that their inactivity increases their chance of having low back pain (LBP) by causing weakness of muscles in the legs, pelvis, and back [28].A sedentary lifestyle that causes a lack of physical exercise impairs muscular strength, power, and the capacity of the spinal disc to hold water at a normal concentration [29].The level of physical activity should be appropriate for the worker's age.According to certain studies, women over the age of 65 who engage in vigorous (at least 20 min of intense physical activity on three or more days per week) or moderate (at least 30 min of moderate-intensity activity on five or more days per week) physical activity are at a significantly greater risk of developing persistent low back pain.After controlling for age and body mass index (BMI), walking for thirty minutes five days a week, and strength training twice a week can reduce the incidence of chronic low back pain (LBP) [30].
According to the current study, bank employees who hold level two job positions and managerial positions are more likely to experience lower back discomfort than those who do not.This could be because bank managers work longer hours, which could be a significant factor contributing to LBP.The associations between being in a managerial position or at the banker level and lower back pain have not been studied.On the other hand, some studies indicate that working long hours at an office increases the risk of low back pain.A study from Bangladesh [12] and Denmark [31], for example, showed that employees who worked longer hours in an office had a greater incidence of low back pain (LBP) than did those who worked fewer hours in a sedentary environment.
Our study also indicates that bank employees who work in a sufficient space have a decreased likelihood of developing LBP compared to those who do not.This can be the result of a decrease in mobility and preoccupation, which leads to back pain due to extended sitting.Working conditions are frequently assumed toplay a significant role in the development of back pain [32].Working in a bent and twisted position for extended periods, bending significantly with the trunk, and performing repetitive activities with the trunk are among the postures linked to it [33][34][35].One study, for instance, from Kigali, Rwanda [13], found that a certain f sitting position could predict the occurrence of back discomfort.Compared to bank employees who sat with their backs straight, those who sat with their backs bent were more likely experience back pain.Similarly, bank employees who used to sit with their backs twisted were more likely to experience back pain than were those who did not.This bad posture can compress and stiffen the lower back, which can cause harm.However, working in a sufficiently spacious environment improves bank workers' well being.For instance, providing ample space for bank workers can lead to better posture and reduce strain on the lower back.This, in turn, may contribute to less low back pain, overall well-being, job satisfaction, reduced healthcare costs for both employees and employers, and decreased absenteeism which translates to financial savings for the organization.When employees experience less pain and discomfort, they are likely to be more productive.Working in comfortable conditions can positively impact focus, concentration, and efficiency and could result in fewer sick days or medical leaves taken by employees due to discomfort or pain.These implications would need to be supported by research and evidence to ensure working in a sufficiently spacious environment plays a role in LBP prevention.

Study limitations
The current study had several limitations.The main limitation of this study was inability to establish a causative relationship between exposure and LBP because of the nature of the study design.The study was conducted through the collection of subjective data via self-administeredquestionnaires, which may be vulnerable to reporting bias due to the respondent'sinterpretation of the questions or their inclination to express their emotions.It is possible that the subjects were unwilling to state the truth or that they had trouble recalling specific details of events or traits.This is because people with LBP do not live a typical life, which lowers their self-esteem.Despite these limitations, this study has important implications for public health, and this information may help develop intervention plans aimed at reducing back pain and its associated risk factors.

Conclusions and recommendations
The magnitude of low back pain among the bank workers was high in the study area.Being in a managerial job position, being a level 2 banker, advanced age, workspace sufficiency, and physical activity were significant factors associated with lower back pain.To minimize the effects on the economy, society, and public health as well as psychological distress, pain catastrophizing, fear of movement, low self-confidence to overcome, poor expectations for recovery, perceptions of greater functional loss, and pain-related challenges, immediate health intervention is needed.It would be preferable to focus on a safe working environment and routine health screening programs for bank employees.It is better to pay special attention toelderly bankers and bank managers.A bank worker who has developed low back pain should consult with healthcare professionals for personal advice.Providing ergonomic workstations and promoting physical activity can mitigate the impact of LBP on bank workers' practices.

Table 3
Behavioral-Related Characteristics of Bank Workers in

Table 4
Low Back Pain-Related Characteristics of Bank Workers in Hawassa City, Northern Zone, Sidama Region, Ethiopia, 2023 (n = 335)

Table 5
Bivariate and multivariate analyses of factors associated with LBP among bank workers in Hawassa City, Northern Zone, Sidama Region, Ethiopia, 2023 (n = 607)